MANUSCRIPT TITLE: The effect of extraction of lower primary canines in the

Accepted Article
morphology of dental arch: a systematic review and meta-analysis.

Keywords: Extraction of deciduous canines, dental arch, interceptive orthodontics,

mixed dentition, systematic review.

Running title: Extraction of primary canines and dental arch

Authors: Daybelis González Espinosa, Crislyne Mendes da Vera Cruz, David Normando.

Author contributions: DN responsible for the guidance of the research, conception and
design of the work, DN, DGE and CM critical review of all phases of the research, data
collection, data analysis and writing of the scientific text.

All authors read and approved the final manuscript.

Department of Orthodontics, Dental School, Federal University of Pará, Augusto Correa

St., no 1. ZIP Code 66075-110.

CORRESPONDING AUTHOR:

Dr. David Normando.

Department of Orthodontics, Dental School, Federal University of Pará, Augusto Correa

St., no 1. Postal Code 66075-110.

Belém, Brazil.

E-mail: davidnormando@hotmail.com

Telephone: +55 91 9144-6316.

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/IPD.12726
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CONFLICT OF INTEREST: none

Word count: 3690, with references.

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Accepted Article
DR. DAVID NORMANDO (Orcid ID : 0000-0002-1335-1040)

Article type : Systematic Review

TITLE: The effect of extraction of lower primary canines on the morphology of the
dental arch: a systematic review and meta-analysis.

ABSTRACT
Background: The beneficial effect of the extraction of primary canines in the resolution of
incisor crowding and its side effects are controversial.
Aim: To systematically review the effects of the extraction of primary canines in dental
crowding and dental arch morphology.
Design: Controlled non-randomized (non-RCT) and randomized clinical trials (RCT)
evaluating children treated with extraction of primary canines compared with those without
intervention.
Results: A total of 984 articles were found, of which two RCTs and one non-RCT met the
inclusion criteria. Both had a low RoB. A high level of evidence was observed through
GRADE. A meta-analysis showed the extraction of primary canines produced a significant
decrease in dental crowding (95%CI: -3.56,-2.09mm). However this decrease was associated
with a reduction of arch length (95%CI: -1.58,-0.94mm), intermolar width (95%CI:-0.61,-
0.22mm) and overjet (95%CI: -075,-018). A mild overbite increase was found (95%CI:
0.10,0.76mm).
Conclusion: A high level of evidence showed that the extraction of primary canines improved
dental crowding in the mixed dentition. Side effects included reduced arch length and
intermolar width. A slight reduction in overjet and a mild increase in overbite were also
observed. When they are not part of the treatment goal, these occlusal changes can be
prevented by installing a lingual arch.

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 Keywords: Extraction of deciduous canines, dental arch, interceptive orthodontics, mixed
Accepted Article
dentition, systematic review.

INTRODUCTION

Dental crowding can be defined as a discrepancy between tooth size and dental arch
dimensions that results in malposition and/or rotation of teeth. In the mixed dentition,
primary dental crowding is caused by tooth size incompatibility between primary and
permanent anterior teeth, generally of genetic origin.1-3 Secondary crowding occurs in the
posterior area due to premature extraction of primary molars, with consequent loss of arch
length. Dental crowding in the mixed dentition is one of the most frequent types of
malocclusion4 with a prevalence of around 33.3-50%.5,6 Associated eruption disorders can
occur and the most frequent are canine impaction and premature, delayed or ectopic
eruption.7,8

The last option to provide space for permanent teeth in tooth size arch length
deficiencies is the extraction of primary teeth. Extraction of primary canines can allow for a
significant relief of crowding of permanent incisors in the mixed dentition.9-15 However, this
procedure could also generate unfavorable side effects on the dental arch such as a decrease
in its length,12-15 a moderate crowding in the permanent dentition8 as a result of less space
available for permanent canines and premolars. Furthermore, a lingual positioning of the
incisors11,12,15 can contribute to arch perimeter reduction and lead to an overbite increase13,14.
The clinical evaluation for the correct indication of treatment for these extractions is highly
dependent on the stage of development of the dentition.10,11
Although extractions of primary teeth are considered a clinical approach in the mixed
dentition, the beneficial effect of this approach in the resolution of incisor crowding during
the early stages of the mixed dentition, and its side effects, such as changes in the arch length,
overbite and overjet, are still controversial. Therefore, it is important to evaluate the

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 methodological quality of clinical studies on the effects of early extraction of the primary
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canines on the dental arch morphology through a systematic review of the literature.

MATERIAL AND METHODS

Record

The present systematic review was recorded in the PROSPERO database

(http://www.crd.york.ac.uk/PROSPERO), under the protocol CRD 42019130590 and
performed according to the PRISMA guidelines (www.prisma-statement.org).

Eligibility Criteria
In the present study, the PICO strategy was used and took into account the following
criteria in the selection of the studies: prospective or retrospective RCT or non-RCT articles
evaluating children (P) treated with extraction of primary canines (I) compared with a control
group without intervention (C), in which the main outcomes were quantitatively assessed
using Little’s irregularity index and gypsum model analysis (O). The outcomes analyzed
were dental crowding, arch length, arch width, overbite and overjet.

Search strategy

A literature search was conducted in the following electronic databases: PubMed,

Cochrane, Scopus, Web of Science, Clinical Trials, Open Gray, LILACS, and Google
Scholar. The references of the selected articles were also evaluated through a manual search
(Appendix - Table 1).
The search for articles was performed without restriction of publication data or
language using keywords based on the PICO strategy and related controlled free terms. The
searches were performed until December, 2019. The selected papers were exported to a
reference manager (EndNote®) for the removal of duplicates and exclusion of those that did
not meet the inclusion criteria.
Selection of studies
The selection of the studies was carried out by two independent examiners (CMVD,
DGE) that accessed the articles separately, and in case of disagreement a third examiner (DN)
was consulted. (Appendix- Table 2)
Extraction of data

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 The data were collected based on the following items: author, year of publication,
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type of study, sample/age, outcomes, follow-up time, intervention, evaluation method,
statistical analysis and author's conclusion. Two independent reviewers (CMVD, DGE)
accessed the articles separately and the inter-examiner conflicts were resolved. In case of
disagreements, a third examiner (DN) was consulted by discussing each paper for consensus.

RoB of included studies

To assess the RoB in non-RCT studies, the ROBINS I-tool ("Risk of Bias In Non-
randomized Studies-of Interventions") was used. This is an index that assesses the RoB by
estimating the comparison of effects (harm or benefit) in studies that do not use random
allocation.

For the classification of the studies, the domains used were grouped into pre-
intervention, intervention, and post-intervention categories (Appendix- Table 3). RoB2 was
used to analyze the risk of publication bias in randomized clinical studies.
(Appendix- Table 3)

All the criteria of both ROBINS I-tool and RoB2 were independently examined by
two researchers, as well as the collection and analysis. A third examiner was consulted in
case of any disagreements.

Analysis of information quality

The results were analyzed through the quality score system GRADE (Grading of
Recommendations, Assessment, Development and Evaluations- https://gradepro.org/).

RESULTS

Selection of studies

After completing the database searches, 1184 articles were found, of which 79 were in
PubMed, 222 in Scopus, 43 in Web of Science, 750 in Google Scholar, 62 in Cochrane, 11 in
Clinical trials, 17 in LILACS and 0 in Open Gray. After removal of duplicates, 984 articles
remained. After reading the titles and abstracts, there were 66 articles remaining to be read in
full. After the exclusion of articles that did not fulfill the inclusion criteria, only three articles

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 were included in the qualitative synthesis13-15 and just two of the three articles were
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evaluated in the quantitative synthesis.13,14 Two RCTs were included in the meta-analysis13-14
since they examined the effect of primary canine extractions on the resolution of dental
crowding and arch dimensions examining similar measurements (Figure 1). The general
characteristics of the three included articles in the qualitative analysis are presented in Table
1.

(Table 1)

Characteristics of the studies

In the qualitative synthesis, three clinical trials13-15 evaluated the extraction of primary
canines to relieve dental crowding; of which, two studies13,14 were randomized, and one15 was
a prospective non-RCT. The mean age of the subjects ranged from 8-9 years.13-15 Regarding
the follow-up time, a variation between one14,15 and two years13 was reported. A greater
variability was observed for sample sizes, ranging from 1615 to 5313 patients for the
intervention group and 1615 and 4114 patients for the control group. In two studies13,15 the
extraction of primary canines was performed in the lower arch and in one14 performed in both
arches.
Regarding the method of evaluation to measure dental crowding, two articles13,14
measured using Little’s irregularity index and one paper15 evaluated dental crowding in the
anterior region. The three articles used plaster models to evaluate arch dimensions.13-15 All of
them used descriptive statistics with mean values and standard deviations for the outcomes
(Table 2).
(Table 2)
Regarding the assessment of the changes in the lower dental arch for crowding, in one
RCT13 a reduction of 6.03 mm was observed in the extraction group and 1.27 mm in the
control group, with a mean difference of 4.76 mm (p<0.05). In the second RCT,14 this
decrease was smaller, 1.88 mm in the extraction group and 0.50 mm in the control group,
with a mean difference of 1.38 mm (p<0.05). The non-RCT study15 did not measure dental
crowding.
In relation to arch length, in the first RCT13 there was a decrease of 3.16 mm in the
extraction group compared to 0.43 mm in the control group (mean difference of 2.73 mm,
p<0.05). In another RCT14 arch length decreased by 1.05 mm for the extraction group and
increased by 0.03 mm for the control group (mean difference of 1.08 mm, p<0.05). In the

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 non-RCT15 there was a decrease of 0.21 mm for the extraction group and an increase of 0.12
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mm for the control group (mean difference of 0.33 mm, p>0.05).
Intermolar width in the first RCT13 decreased 0.11 mm in the extraction group and
increased 0.32 mm in the control group, and had a mean difference of 0.43 mm (p>0.05). In
the second RCT,14 there was a decrease of 0.18 mm in the extraction group and an increase of
0.23 mm in the control group, mean difference of 0.41 mm (p<0.05). The non-RCT study15
showed increases of 0.32 mm and 0.39 mm in the extraction and control groups respectively,
mean difference of 0.07 mm (p>0.05).
Regarding overbite, there were increases of 0.76 mm for the extraction group and 0.37
mm for the control group, with a mean difference of 0.39 mm (p>0.05), in the first RCT.13 In
the second RCT14 an increase of 0.58 mm for the extraction group and 0.10 mm for the
control group was reported, mean difference of 0.48 mm (p>0.05). Overbite was not
evaluated in the non-RCT study.15
The overjet in the first RCT13 decreased 0.12 mm for the extraction group and
increased 0.28 mm for the control group, with an average difference of 0.4 mm (p>0.05). In
the second RCT14 there was a decrease of 0.35 mm for the extraction group and a 0.16 mm
increase for the control group, with an average difference 0.51 mm (p<0.05). Overjet was not
evaluated in the non-RCT study.15

Individual RoB
In the RoB analysis of the included studies, one of the articles15 was evaluated using
the ROBINS I-tool ("Risk of Bias in Non-randomized Studies of Interventions") which
obtained a low RoB (Table 3).
RoB2 was used to analyze the publication bias of the other two13,14 RCTs included in
the analysis and both were classified as having a low RoB (Table 4).
(Tables 3 and 4)

Meta-analysis

In the quantitative analysis, four variables were analyzed using plaster models: dental
crowding, arch length, intermolar width, overjet, and overbite. In the meta-analysis, both
RCTs were included13,14 because they presented greater homogeneity for the outcomes.

The two articles13,14 had a total sample of 85 patients for the intervention group and 71
patients in the control group. Concerning anterior dental crowding and dental arch length, a

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 significant decrease was observed in the extraction group (-2.83 mm 95%CI: -3.56, -2.09.
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p<0.0001, Figure 2) and (-1.26 mm 95%CI: -1.58, -0.94. p<0.0001, Figure 3), respectively.
The intermolar width showed a significant difference with a mean of -0.41 mm (95%CI: -
0.61, -0.22. p<0.0001, Figure 4) affecting the intervention group more.

There was a significant overbite increase for both groups, but it was higher for the
extraction group, mean of 0.43 (95%CI: 0.10, 0.76. p<0.01, Figure 5). In the overjet, while
the extraction group showed a slight reduction, the control group presented an increase, mean
difference of 0.46 mm (95%CI: -075,-018), p< 0.01, Figure 6). Only arch length and overbite
variables showed a greater heterogeneity with p<0.01.

Quality of evidence analysis.

Results obtained through GRADE showed a "high" level of evidence regarding the
measures analyzed in the meta-analysis (Table 5). These results point to a greater consistency
and precision of the analyzed studies, but only three measurements (arch length, intermolar
width, and overjet) increased their scores due to the magnitude of the effect.
(Table 5)

DISCUSSION

Changes that occur in the dimension of the dental arch is a key factor to determine an
appropriate interceptive treatment for dental crowding in the mixed dentition. During the
transition from mixed to permanent dentition, a reduction of around 3-4 mm can occur in arch
perimeter16 due to physiologic mesial migration of first permanent molars. Lingual arch can
be useful to avoid molar mesial migration and to maintain leeway space. A recent systematic
review17 reported that the lower lingual arch was effective in resolving mandibular incisor
crowding of around 5 mm without any significant arch perimeter or arch length changes.

Some children will need more than 5-6 millimeters of space. In such cases, an option
would be lower arch expansion with a lip bumper. This appliance produces buccal inclination
of the incisors and distal inclination of the permanent first molars, which increases perimeter
and arch length.18 An increase in the arch width was also reported. However, this therapy
increased the risk of second molar impaction; and, due to the proclination of the incisors, it

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 would be contraindicated in patients with incisor protrusion. For these cases, tooth size
Accepted Article
reduction should be considered.

The last option to provide space for permanent teeth in severe tooth size arch length
deficiencies is the extraction of primary teeth. Since the primary crowding begins in the
region of the permanent incisors, during the early mixed dentition, the deciduous canines are
usually the first choice for extraction. Although extraction can be postponed, early treatment
can be associated with less relapse and reduced active orthodontic treatment time.19 In
addition to aesthetics improvement, early extraction can promote the eruption of poorly
positioned permanent successors10,20 and facilitate the eruption of permanent teth through the
keratinized gingival mucosa, favoring periodontal health. However, this procedure has the
potential to cause arch perimeter reduction and aggravate the tooth size arch length
deficiency when the child later reaches permanent dentition.

In the present study we systematically reviewed the effect of extraction of deciduous

canines in dental crowding, arch dimensions and incisor relations in the mixed dentition.
Results obtained through GRADE showed a "high" level of evidence regarding the outcomes
evaluated. Concerning dental crowding, a significant decrease was observed 1-1.5 years after
canine extraction (95%CI: -3.56, -2.09). However, a side effect of extraction is an arch length
reduction. Some slight decreases in intermolar widths were also observed. Thus, extraction
seems to increase the physiological process of reduction in dental arch length. These side
effects can disturb the eruption of permanent canines due to an arch perimeter reduction.

Another disadvantage of early extraction is that it could be considered an invasive

treatment for children. As a result, it can induce negative responses to treatment and generate
possible traumatic experiences in children, causing discomfort and aversion to dental
care.21,22 The advantage of extractions is believed to be the improvement of early tooth
alignment and some reduction of orthodontic treatment time.19

Furthermore, this review consistently reports that extraction of the primary canine can
slightly alter the position of permanent incisors, causing a reduction in the overjet and an
increase in the overbite. An increase in overbite is a change probably associated with lingual
inclination increase of the incisors.15 However, an increase in overjet would not be expected
since, among the two studies included in the meta-analysis13,14, one of them13 performed
canine extractions only in the lower arch. Even so, the results of the two studies showed a

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 consistent reduction in the overjet in the group with extraction of 0.46 mm (95% CI: -075, -
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018). Nevertherless, t is necessary to consider several factors that act on the incisors
influencing their eruption and alignment. Among these factors are muscular imbalances, such
as deleterious habits such as pacifier use22, thumb sucking, tongue pressure and mouth
breathing.

Limitations
Regarding the limitations of the primary studies, some features in the included studies
should be discussed. Regarding the two RCTs, while one examined the effects of primary
canine extractions in both arches, the other examined the effects only in the lower arch, as
well as the non-RCT. There are still methodological differences, mainly between the two
RCTs and the non-RCT, regarding the outcomes that were evaluated.
Furthermore, this systematic review includes only studies with less than two years of
follow-up. Studies with a longer follow-up period, from the beginning of mixed dentition to
permanent dentition, are necessary.
Since early extraction of deciduous canines may be the only treatment choice for
borderline cases in the early mixed dentition, the results of this systematic review suggests a
lingual arch in order to prevent loss of arch length and arch width, together with changes in
incisor position. RCTs addressing the efficiency of this protocol in a long term are
recommended.

CONCLUSION
We can conclude that, while extraction of primary canines relieves dental crowding in
the mixed dentition, a decrease in the dimensions of the dental arch is a side effect which may
be critical in the development of the permanent dentition. A slight reduction in overjet and a
mild increase in overbite was also observed. When they are not part of the treatment goal,
these changes can be prevented by installing a lingual arch. RCTs addressing the efficiency
of primary canine extractions associated with a lingual arch are recommended.

BULLET POINTS
 Extraction of primary canines is a usual clinical procedure in the resolution of incisor
crowding during the early stages of the mixed dentition and most of these clinical
approaches are performed by Paediatric Dentists.

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  A systematic review of clinical studies on the effects of early extraction of the
Accepted Article primary canines on the dental arch morphology is justified to evaluate the
methodological quality of clinical studies.
 A high level of evidence showed that extractions of primary canines can relieve
dental crowding in the mixed dentition. However, reduced arch length and intermolar
width are side effects. A slight reduction in overjet and a mild increase in overbite
was also observed. When they are not part of the treatment goal, these changes can be
prevented by installing a lingual arch.

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 9. Yoshihara T, Matsumoto Y, Suzuki J, Sato N, Oguchi H. Effect of serial extraction alone
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14. Sjögren A, Arnrup K, Lennartsson B, Huggare J. Mandibular incisor alignment and dental
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FIGURE LEGENDS:
Figure 1: Flow chart of the selection process
Figure 2: Forest plot on the crowding differences between the extraction group and the
control group.
Figure 3: Forest plot on the differences in length of the lower arch between the extraction
group and the control group.
Figure 4: Forest plot on the differences of the intermolar width of the lower arch between the
extraction group and the control group.
Figure 5: Forest plot on the differences of overbite between the extraction group and the
control group.
Figure 6: Forest plot on the differences of overjet between the extraction group and the
control group.

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 APPENDIX:
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Table 1: Search strategy.

Database Search strategy

Pubmed #23 Search (((((((((child[MeSH Terms]) OR child[Title/Abstract]) OR childrens[Title/Abstract])) OR (((((((child
health[MeSH Terms]) OR child health[Title/Abstract]) OR Children's Health[Title/Abstract]) OR Childrens
Health[Title/Abstract]) OR Health, Child[Title/Abstract]) OR Health, Children's[Title/Abstract]) OR Health,
Childrens[Title/Abstract])) OR ((((((((((((((((((adolescent[MeSH Terms]) OR Adolescent[Title/Abstract]) OR
Adolescents, Female[Title/Abstract]) OR Adolescents, Male[Title/Abstract]) OR Teenagers[Title/Abstract]) OR
Teens[Title/Abstract]) OR Adolescent, Female[Title/Abstract]) OR Adolescent, Male[Title/Abstract]) OR Female
Adolescent[Title/Abstract]) OR Female Adolescents[Title/Abstract]) OR Male Adolescent[Title/Abstract]) OR
Male Adolescents[Title/Abstract]) OR Teen[Title/Abstract]) OR Teenager[Title/Abstract]) OR
Youths[Title/Abstract]) OR Adolescence[Title/Abstract]) OR Youth[Title/Abstract]))) AND (((((((((dentition
mixed[MeSH Terms]) OR dentition mixed[Title/Abstract]) OR Dentitions, Mixed[Title/Abstract]) OR
Dentitions, Transitional[Title/Abstract]) OR Mixed Dentition[Title/Abstract]) OR Mixed
Dentitions[Title/Abstract]) OR Transitional Dentition[Title/Abstract]) OR Transitional
Dentitions[Title/Abstract]) OR Dentition, Transitional[Title/Abstract])) OR ((((((((((((((((((((((((tooth
deciduos[MeSH Terms]) OR tooth deciduos[Title/Abstract]) OR Baby Teeth[Title/Abstract]) OR Baby
Tooth[Title/Abstract]) OR Dentition, Deciduous[Title/Abstract]) OR Dentition, Primary[Title/Abstract]) OR
Milk Teeth[Title/Abstract]) OR Primary Teeth[Title/Abstract]) OR Teeth, Deciduous[Title/Abstract]) OR Teeth,
Primary[Title/Abstract]) OR Deciduous Dentition[Title/Abstract]) OR Deciduous Dentitions[Title/Abstract]) OR
Deciduous Teeth[Title/Abstract]) OR Deciduous Tooth[Title/Abstract]) OR Dentitions,
Deciduous[Title/Abstract]) OR Dentitions, Primary[Title/Abstract]) OR Primary Dentition[Title/Abstract]) OR
Primary Dentitions[Title/Abstract]) OR Teeth, Baby[Title/Abstract]) OR Teeth, Milk[Title/Abstract]) OR Tooth,
Baby[Title/Abstract]) OR Tooth, Milk[Title/Abstract]) OR Primary Tooth[Title/Abstract]) OR Tooth,
Primary[Title/Abstract]))) AND ((((((((((((((((((crowding[MeSH Terms]) OR crowding[Title/Abstract]) OR
Cross Bite[Title/Abstract]) OR Angle Classification[Title/Abstract]) OR Angles Classification[Title/Abstract])
OR Bite, Cross[Title/Abstract]) OR Bites, Cross[Title/Abstract]) OR Classification, Angle's[Title/Abstract]) OR
Cross Bites[Title/Abstract]) OR Crossbites[Title/Abstract]) OR Crowding, Tooth[Title/Abstract]) OR Crowdings,
Tooth[Title/Abstract]) OR Malocclusions[Title/Abstract]) OR Tooth Crowding[Title/Abstract]) OR
Crossbite[Title/Abstract]) OR Angle's Classification[Title/Abstract])) OR (((incisor crowding[MeSH Terms]) OR
incisor crowding[Title/Abstract]) OR crowding[Title/Abstract]))

#24 Search ((((((((((cuspid[MeSH Terms]) OR cuspid[Title/Abstract]) OR Canine Teeth[Title/Abstract]) OR

Cuspids[Title/Abstract]) OR Teeth, Canine[Title/Abstract]) OR Tooth, Canine[Title/Abstract]) OR Canine
Tooth[Title/Abstract])) AND (((((tooth extraction[MeSH Terms]) OR tooth extraction[Title/Abstract]) OR
Extraction, Tooth[Title/Abstract]) OR Extractions, Tooth[Title/Abstract]) OR Tooth Extractions[Title/Abstract]))
OR (((extraction of primary canines[MeSH Terms]) OR extraction of primary canines[Title/Abstract]) AND
extraction of primary canines[Title/Abstract])) OR (((orthodontics interceptive[MeSH Terms]) OR orthodontics
interceptive[Title/Abstract]) OR interceptive orthodontics[Title/Abstract])
Final search: #23 AND #24 (((((((((((child[MeSH Terms]) OR child[Title/Abstract]) OR
childrens[Title/Abstract])) OR (((((((child health[MeSH Terms]) OR child health[Title/Abstract]) OR Children's
Health[Title/Abstract]) OR Childrens Health[Title/Abstract]) OR Health, Child[Title/Abstract]) OR Health,
Children's[Title/Abstract]) OR Health, Childrens[Title/Abstract])) OR ((((((((((((((((((adolescent[MeSH Terms])
OR Adolescent[Title/Abstract]) OR Adolescents, Female[Title/Abstract]) OR Adolescents, Male[Title/Abstract])
OR Teenagers[Title/Abstract]) OR Teens[Title/Abstract]) OR Adolescent, Female[Title/Abstract]) OR

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 Adolescent, Male[Title/Abstract]) OR Female Adolescent[Title/Abstract]) OR Female
Accepted Article Adolescents[Title/Abstract]) OR Male Adolescent[Title/Abstract]) OR Male Adolescents[Title/Abstract]) OR
Teen[Title/Abstract]) OR Teenager[Title/Abstract]) OR Youths[Title/Abstract]) OR Adolescence[Title/Abstract])
OR Youth[Title/Abstract]))) AND (((((((((dentition mixed[MeSH Terms]) OR dentition mixed[Title/Abstract])
OR Dentitions, Mixed[Title/Abstract]) OR Dentitions, Transitional[Title/Abstract]) OR Mixed
Dentition[Title/Abstract]) OR Mixed Dentitions[Title/Abstract]) OR Transitional Dentition[Title/Abstract]) OR
Transitional Dentitions[Title/Abstract]) OR Dentition, Transitional[Title/Abstract])) OR ((((((((((((((((((((((((tooth
deciduos[MeSH Terms]) OR tooth deciduos[Title/Abstract]) OR Baby Teeth[Title/Abstract]) OR Baby
Tooth[Title/Abstract]) OR Dentition, Deciduous[Title/Abstract]) OR Dentition, Primary[Title/Abstract]) OR
Milk Teeth[Title/Abstract]) OR Primary Teeth[Title/Abstract]) OR Teeth, Deciduous[Title/Abstract]) OR Teeth,
Primary[Title/Abstract]) OR Deciduous Dentition[Title/Abstract]) OR Deciduous Dentitions[Title/Abstract]) OR
Deciduous Teeth[Title/Abstract]) OR Deciduous Tooth[Title/Abstract]) OR Dentitions,
Deciduous[Title/Abstract]) OR Dentitions, Primary[Title/Abstract]) OR Primary Dentition[Title/Abstract]) OR
Primary Dentitions[Title/Abstract]) OR Teeth, Baby[Title/Abstract]) OR Teeth, Milk[Title/Abstract]) OR Tooth,
Baby[Title/Abstract]) OR Tooth, Milk[Title/Abstract]) OR Primary Tooth[Title/Abstract]) OR Tooth,
Primary[Title/Abstract]))) AND ((((((((((((((((((crowding[MeSH Terms]) OR crowding[Title/Abstract]) OR
Cross Bite[Title/Abstract]) OR Angle Classification[Title/Abstract]) OR Angles Classification[Title/Abstract])
OR Bite, Cross[Title/Abstract]) OR Bites, Cross[Title/Abstract]) OR Classification, Angle's[Title/Abstract]) OR
Cross Bites[Title/Abstract]) OR Crossbites[Title/Abstract]) OR Crowding, Tooth[Title/Abstract]) OR Crowdings,
Tooth[Title/Abstract]) OR Malocclusions[Title/Abstract]) OR Tooth Crowding[Title/Abstract]) OR
Crossbite[Title/Abstract]) OR Angle's Classification[Title/Abstract])) OR (((incisor crowding[MeSH Terms]) OR
incisor crowding[Title/Abstract]) OR crowding[Title/Abstract])))) AND (((((((((((cuspid[MeSH Terms]) OR
cuspid[Title/Abstract]) OR Canine Teeth[Title/Abstract]) OR Cuspids[Title/Abstract]) OR Teeth,
Canine[Title/Abstract]) OR Tooth, Canine[Title/Abstract]) OR Canine Tooth[Title/Abstract])) AND (((((tooth
extraction[MeSH Terms]) OR tooth extraction[Title/Abstract]) OR Extraction, Tooth[Title/Abstract]) OR
Extractions, Tooth[Title/Abstract]) OR Tooth Extractions[Title/Abstract])) OR (((extraction of primary
canines[MeSH Terms]) OR extraction of primary canines[Title/Abstract]) AND extraction of primary
canines[Title/Abstract])) OR (((orthodontics interceptive[MeSH Terms]) OR orthodontics
interceptive[Title/Abstract]) OR interceptive orthodontics[Title/Abstract]))

Scopus Final search; health" * ) OR TITLE-ABS-KEY ( "Children's Health" ) OR TITLE-ABS-KEY ( "Childrens

Health" ) OR TITLE-ABS-KEY ( "Health,Child" ) OR TITLE-ABS-KEY ( "Health,Children's" ) OR TITLE-
ABS-KEY ( "Health,Childrens" ) ) ) OR ( ( TITLE-ABS-KEY ( adolescent* ) OR TITLE-ABS-
KEY ( adolescents ) OR TITLE-ABS-KEY ( "Adolescents, Female" ) OR TITLE-ABS-KEY ( "Adolescents,
Male" ) OR TITLE-ABS-KEY ( teenagers ) OR TITLE-ABS-KEY ( teens ) OR TITLE-ABS-
KEY ( "Adolescent, Female" ) OR TITLE-ABS-KEY ( "Adolescent, Male" ) OR TITLE-ABS-KEY ( "Female
Adolescent" ) OR TITLE-ABS-KEY ( "Female Adolescents" ) OR TITLE-ABS-KEY ( "Male
Adolescent" ) OR TITLE-ABS-KEY ( "Male Adolescents" ) OR TITLE-ABS-KEY ( teen ) OR TITLE-ABS-
KEY ( teenager ) OR TITLE-ABS-KEY ( youths ) OR TITLE-ABS-KEY ( adolescence ) OR TITLE-ABS-
KEY ( youth AND ) ) ) OR ( ( TITLE-ABS-KEY ( "dentition mixed" * ) OR TITLE-ABS-
KEY ( "Dentitions, Mixed" ) OR TITLE-ABS-KEY ( "Dentitions, Transitional" ) OR TITLE-ABS-
KEY ( "Mixed Dentition" ) OR TITLE-ABS-KEY ( "Mixed Dentitions" ) OR TITLE-ABS-
KEY ( "Transitional Dentition" ) OR TITLE-ABS-KEY ( "Transitional Dentitions" ) OR TITLE-ABS-
KEY ( "Dentition, Transitional" ) ) ) OR ( ( TITLE-ABS-KEY ( "tooth deciduos" * ) OR TITLE-ABS-
KEY ( "Baby Teeth" ) OR TITLE-ABS-KEY ( "Baby Tooth" ) OR TITLE-ABS-
KEY ( "Dentition,Deciduous" ) OR TITLE-ABS-KEY ( "Dentition,Primary" ) OR TITLE-ABS-KEY ( "Milk
Teeth" ) OR TITLE-ABS-KEY ( "Milk Tooth" ) OR TITLE-ABS-KEY ( "Primary Teeth" ) OR TITLE-ABS-
KEY ( "Teeth,Deciduous" ) OR TITLE-ABS-KEY ( "Teeth,Primary" ) OR TITLE-ABS-KEY ( "Deciduous
Dentition" ) OR TITLE-ABS-KEY ( "Deciduous Dentitions" ) OR TITLE-ABS-KEY ( "Deciduous
Teeth" ) OR TITLE-ABS-KEY ( "Deciduous Tooth" ) OR TITLE-ABS-

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 KEY ( "Dentitions,Deciduous" ) OR TITLE-ABS-KEY ( "Dentitions,Primary" ) OR TITLE-ABS-
Accepted Article KEY ( "Primary Dentition" ) OR TITLE-ABS-KEY ( "Primary
KEY ( "Teeth,Baby" ) OR TITLE-ABS-KEY ( "Teeth,Milk" ) OR TITLE-ABS-
Dentitions" ) OR TITLE-ABS-

KEY ( "Tooth,Baby" ) OR TITLE-ABS-KEY ( "Tooth,Milk" ) OR TITLE-ABS-KEY ( "Primary

Tooth" ) OR TITLE-ABS-KEY ( "Tooth,Primary" ) ) ) AND ( ( TITLE-ABS-KEY ( crowding* ) OR TITLE-
ABS-KEY ( "Cross Bite" ) OR TITLE-ABS-KEY ( "Angle Classification" ) OR TITLE-ABS-KEY ( "Angles
Classification" ) OR TITLE-ABS-KEY ( "Bite, Cross" ) OR TITLE-ABS-KEY ( "Bites, Cross" ) OR TITLE-
ABS-KEY ( "Classification, Angle's" ) OR TITLE-ABS-KEY ( "Cross Bites" ) OR TITLE-ABS-
KEY ( crossbites ) OR TITLE-ABS-KEY ( "Crowding, Tooth" ) OR TITLE-ABS-KEY ( "Crowdings,
Tooth" ) OR TITLE-ABS-KEY ( malocclusions ) OR TITLE-ABS-KEY ( "Tooth Crowding" ) OR TITLE-
ABS-KEY ( crossbite ) OR TITLE-ABS-KEY ( "Angle's Classification" ) ) ) OR ( ( TITLE-ABS-
KEY ( "incisor crowding" * ) OR TITLE-ABS-KEY ( "incisor crowding" ) OR TITLE-ABS-
KEY ( crowding ) ) ) ) AND ( ( ( TITLE-ABS-KEY ( cuspid* ) OR TITLE-ABS-KEY ( "Canine
Teeth" ) OR TITLE-ABS-KEY ( cuspids ) OR TITLE-ABS-KEY ( "Teeth, Canine" ) OR TITLE-ABS-
KEY ( "Tooth, Canine" ) OR TITLE-ABS-KEY ( "Canine Tooth" ) ) ) AND ( ( TITLE-ABS-KEY ( "tooth
extraction" * ) OR TITLE-ABS-KEY ( "Extraction, Tooth" ) OR TITLE-ABS-KEY ( "Extractions,
Tooth" ) OR TITLE-ABS-KEY ( "Tooth Extractions" ) ) ) OR ( ( TITLE-ABS-KEY ( "tooth
extraction" * ) OR TITLE-ABS-KEY ( "Extraction, Tooth" ) OR TITLE-ABS-KEY ( "Extractions,
Tooth" ) OR TITLE-ABS-KEY ( "Tooth Extractions" ) ) ) OR ( ( TITLE-ABS-KEY ( "extraction of primary
canines" * ) OR TITLE-ABS-KEY ( "extraction of primary canines" ) ) ) OR ( ( TITLE-ABS-
KEY ( "orthodontics interceptive" * ) OR TITLE-ABS-KEY ( "orthodontics interceptive" ) OR TITLE-ABS-
KEY ( "Interceptive Orthodontics" ))))

The #1 (child$):ti,ab,kw OR (childrens):ti,ab,kw (Word variations have been searched) 111060

Cochrane #2 ("child health$"):ti,ab,kw OR ("Children's Health"):ti,ab,kw OR ("Childrens Health"):ti,ab,kw OR
Library ("Health, Child"):ti,ab,kw OR ("Health, Children's"):ti,ab,kw (Word variations have been searched)
2801 #3 ("child health$"):ti,ab,kw OR ("Health, Childrens"):ti,ab,kw (Word variations have been
searched) 2681
#4 (Adolescent$):ti,ab,kw OR (Adolescents):ti,ab,kw OR ("Adolescents, Female"):ti,ab,kw OR
("Adolescents, Male"):ti,ab,kw OR (Teenagers):ti,ab,kw (Word variations have been searched) 120315 #5
(Adolescent$):ti,ab,kw OR (Teens):ti,ab,kw OR ("Adolescent, Female"):ti,ab,kw OR ("Adolescent,
Male"):ti,ab,kw OR (Female Adolescent):ti,ab,kw (Word variations have been searched) 120315 #6
(Adolescent$):ti,ab,kw OR ("Female Adolescents"):ti,ab,kw OR ("Male Adolescent"):ti,ab,kw OR
("Male Adolescents"):ti,ab,kw OR (Teen):ti,ab,kw (Word variations have been searched) 120316
#7 (Adolescent$):ti,ab,kw OR (Teenager):ti,ab,kw OR (Youths):ti,ab,kw OR (Adolescence):ti,ab,kw OR
(Youth):ti,ab,kw (Word variations have been searched) 121840 #8 ("detition mixed$"):ti,ab,kw OR ("Dentitions,
Mixed"):ti,ab,kw OR ("Dentitions, Transitional"):ti,ab,kw OR ("Mixed Dentition"):ti,ab,kw OR ("Mixed
Dentitions"):ti,ab,kw (Word variations have been searched) 137 #9 (crowding$):ti,ab,kw OR ("Cross
Bite"):ti,ab,kw OR ("Angle Classification"):ti,ab,kw OR ("Angles Classification"):ti,ab,kw OR ("Bite,
Cross"):ti,ab,kw (Word variations have been searched) 441 #10 (crowding$):ti,ab,kw OR ("Bites,
Cross"):ti,ab,kw OR ("Classification, Angle's"):ti,ab,kw OR ("Cross Bites"):ti,ab,kw OR (Crossbites):ti,ab,kw
(Word variations have been searched) 496
#11 (crowding$):ti,ab,kw OR ("Crowding, Tooth"):ti,ab,kw OR ("Crowdings, Tooth"):ti,ab,kw OR
(Malocclusions):ti,ab,kw OR ("Tooth Crowding"):ti,ab,kw (Word variations have been searched) 1359 #12
(crowding$):ti,ab,kw OR (Crossbite):ti,ab,kw OR ("Angle's Classification"):ti,ab,kw (Word variations
have been searched) 498
#13 ("incisor crowding$"):ti,ab,kw OR ("incisor crowding"):ti,ab,kw (Word variations have been
searched) 12
#14 (cuspid$):ti,ab,kw OR ("Canine Tooth"):ti,ab,kw (Word variations have been searched) 421 #15

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 (tooth extraction$):ti,ab,kw OR ("Extraction, Tooth"):ti,ab,kw OR ("Extractions, Tooth"):ti,ab,kw OR
Accepted Article ("Tooth Extractions"):ti,ab,kw (Word variations have been searched)
canines$"):ti,ab,kw (Word variations have been searched) 0
4144 #16 ("extraction of primary

#17 ("dental arch$"):ti,ab,kw OR ("Arch, Dental"):ti,ab,kw OR ("Arches, Dental"):ti,ab,kw OR ("Dental

Arches"):ti,ab,kw (Word variations have been searched) 311
#18 ("dentition mixed$"):ti,ab,kw OR ("Transitional Dentition"):ti,ab,kw OR ("Transitional
Dentitions"):ti,ab,kw OR ("Dentition, Transitional"):ti,ab,kw (Word variations have been searched)78 #19
(cuspid$):ti,ab,kw OR ("Canine Teeth"):ti,ab,kw OR ("Teeth, Canine"):ti,ab,kw OR ("Tooth,
Canine"):ti,ab,kw OR (cuspids):ti,ab,kw (Word variations have been searched) 427
#20 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 192373
#21 ("tooth deciduos$"):ti,ab,kw OR ("Baby Teeth"):ti,ab,kw OR ("Baby Tooth"):ti,ab,kw OR ("Dentition,
Deciduous"):ti,ab,kw OR ("Dentition, Primary"):ti,ab,kw (Word variations have been searched) 19
#22 ("tooth deciduos$"):ti,ab,kw OR ("Milk Teeth"):ti,ab,kw OR ("Milk Tooth"):ti,ab,kw OR ("Primary
Teeth"):ti,ab,kw OR ("Teeth, Deciduous"):ti,ab,kw (Word variations have been searched) 789
#23 ("tooth deciduos$"):ti,ab,kw OR ("Teeth, Primary"):ti,ab,kw OR ("Deciduous Dentition"):ti,ab,kw OR
("Deciduous Dentitions"):ti,ab,kw OR ("Deciduous Teeth"):ti,ab,kw (Word variations have been searched)
191
#24 ("tooth deciduos$"):ti,ab,kw OR ("Deciduous Tooth"):ti,ab,kw OR ("Dentitions, Deciduous"):ti,ab,kw
OR ("Dentitions, Primary"):ti,ab,kw OR ("Primary Dentition"):ti,ab,kw (Word variations have been searched)
250
#25 ("tooth deciduos$"):ti,ab,kw OR ("Primary Dentitions"):ti,ab,kw OR ("Teeth, Baby"):ti,ab,kw OR
("Teeth, Milk"):ti,ab,kw OR ("Tooth, Baby"):ti,ab,kw (Word variations have been searched) 95
#26 ("tooth deciduos$"):ti,ab,kw OR ("Tooth, Milk"):ti,ab,kw OR ("Primary Tooth"):ti,ab,kw OR ("Tooth,
Primary"):ti,ab,kw (Word variations have been searched) 482
#27 #8 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26 1034
#28 #9 OR #10 OR #11 OR #12 OR #13 1382
#29 #14 AND #15 OR #16 96
#30 #20 AND #27 AND #28 94
#31 ("orthodontics interceptive$"):ti,ab,kw OR ("Interceptive Orthodontics"):ti,ab,kw (Word variations
have been searched) 57
#32 #20 AND #29
child [Palavras]
Lilacs and canines [Palavras] and extraction [Palavras]

Google child OR adolescent + crowding + primary canine + dental extraction + orthodontics interceptive
Scholar

Clinical Primary canines extraction

Trials

OpenGrey primary canines AND extraction

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 Appendix 2: Reason for exclusion for articles read in full.
Accepted Article
AUTHOR
Alamoudi NM. (2019)
Al-Dulayme Al et al. (2010)
Al-Sehaibany. (2011)
Atkinson CD. (1982)
Bell RA et al. (2014)
Bhujel N et al. (2014)
Bonneti GA et al. (2010)
Bonneti GA et al.(2011)
Cabral VSB et al. (2018)
Cheney EA et al.(1958)
Derry, C. (1982)
Dibiase, A. (2002)
Esperanza et al. (1986)
Fattahi H et al. (2012)
Feldman E. (2014).
Flores, MAP et al.(2009)
Flores-Mir C et al. (1990)
Foley T et al. (1996)
Fujita T et al. (1988)
Gianelly AA. (2002)
Gontsova G et al. (1985)
Jolley CJ et al. (2010)
Jonsson T et al. (2010)
Junior PAM et al. (2012)
Kaur J et al. (2015)
Kerosuo H. (2012)
Kim E et al. (2003)
King GJ et al. (2010)
King GJ et al. (2012)
Krunsinskiene V. (2010)
Langberg BJ. et al. (2000)
Lee,SH. (2015)
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REASON FOR REASON FOR
EXCLUSION AUTHOR EXCLUSION
Studies with duplicate
Other research objective Leonardi M et al. (2004) samples
Other research objective Little, RM. (2002) Other research objective
Studies with duplicate
Other research objective Mantysaami M et al. (2004) samples
Clinical case report Mišurcová H et al. (2006) Other research objective
Literature review Moshkelgosha, V et al. (2018) Other research objective
Other research objective Mueller BH et al. (1978). Not recovered
Clinical case report Myrlund R et al. (2015) Other research objective
Other research objective Naomova, J et al (2014) Other research objective
Studies with duplicate
Clinical case report Naomova J et al. (2014) samples
Studies with duplicate
Other research objective Naomova J et al. (2015) samples
Other research objective Naomova J et al. (2018) Other research objective
Literature review Ngan P et al.(1999) Literature review
Literature review Nunn R et al. (2011) Other research objective
Other research objective Parkin N et al (2017) Other research objective
Other research objective Rerhrhaye W et al. (2011) Clinical case report
Other research objective Roberto M et al. (1970) Literature review
Editorial Rönnerman A. (1966) Not recovered
Literature review Rublevsky DV. (2012) Other research objective
Not recovered Saloom HF. (2005) Other research objective
Other research objective Sampson WJ et al.(1985) Other research objective
Other research objective Siersbaek N et al (1973) Other research objective
Other research objective Sivakumar A et al. (2012) Literature review
Other research objective Sjögren A. (2011) Literature review
Clinical case report Smailiêne D et al (2011) Other research objective
Clinical case report Stahl F et al. (2003) Other research objective
Literature review Suga SS. (2008) Other research objective
Other research objective Thilloy G et al. (1972) Not recovered
Other research objective Vendittelli BL et al. (2017) Literature review
Other research objective Winnier JJ et al. (2015) Literature review
Other research objective Yoshihara,T et al. (1999) Other research objective
Other research objective Zreaqat, MH. (2014) Other research objective
Literature review --- ---
 Table 1: Domains used for classification of articles were grouped in pre, during and post-intervention for the
Accepted Article
ROBINS I-tool.

DOMAINS OF BIAS DESCRIPTION

PRE-INTERVENTION

Risk of bias due to Baseline assessment of several participants by age and who presented the
confusion. description of the dental crowding.
Variable time finding: Follow-up time.
Risk of bias in the Finding the inclusion and exclusion criteria for the selection of the participants.
selection of study Exclusion of some eligible participants or follow-up time for some participants.
participants.

INTERVENTION

Risk of bias in the When the intervention status was not described correctly.
intervention Use of additional orthodontic methods for treatment of crowding or other
classification. malocclusion.

POST-INTERVENTION

Risk of bias due to a When there were systematic differences between the intervention group (canine
deviation from planned extraction) and the control group, or when there was no information on crowding
intervention. treatment provided in case of absence of control group.

Risk of bias due to lack In case of loss of follow-up, incomplete collection of data and exclusion of
of data. participants from the analysis.
Risk of bias in the When the measures analyzed in the study models were disqualified or measured
measurement of results. with error.

When they did not present the measures established in the different times of
treatment.
Risk in the selection of Selective reporting of results when the effect of all measurements of results has not
reported results. been fully reported.

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 Table 1: Data extraction from included studies.
Accepted Article
AUTHOR Kau et al. 13 Sjögren et al. 14 Sayin et al.15

YEAR 2004 2012 2006

TYPE OF STUDY Randomized clinical trial Randomized clinical trial Prospective clinical study

SAMPLE/ AGE Extraction: 53 Extraction: 32 (M:14 /F:18) Extraction: 16

8-9 years 8.8-8.5 years (M:5/F:11)/8.9 years
Control: 30 Control: 41 (M:16 /F:25) Control: 16 (M:5/ F:11)
8-9 years 8.8-8.5 years 8.9 years

Initial Little index ≥ 6 Little's index Extraction Group: initial

OUTCOMES mm (initial crowding) Extraction Group: initial crowding > 1.6mm
Overbite crowding (2/3 mesiodistal Control Group: initial
width of mandibular central crowding <1.6mm
incisor)  Arch length
Overbite  Intermolar width
Overjet  Interalveolar width

Minimum: 1 year
FOLLOW-UP Extraction: 19 m 1 year 1 year
Control: 16 m

Extraction of lower Extraction of upper and lower Extraction of lower canines

INTERVENTION canines canines

METHOD Plaster model Plaster model/ Digital Plaster model and

photography/ Family cephalometric radiography
assessment/
Professional assessment

STATISTICAL Independent t test / Mann- Paired and independent t-

ANALYSIS Mann-Whitney test Whitney U test, χ 2-U test, tests
Wilcoxon t-test signed-rank
AUTHOR'S Crowding of the lower A slight improvement in tooth In the extraction group, the
CONCLUSION incisors and arch length alignment and rotation of the only significant change was
decreased significantly in incisors were clinically the retrusion of the lower
the extraction group. detectable, as well as a incisors. No significant
decrease in arch length in the effect of extraction was
extraction group, while determined on the length

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 dimensions were preserved in and width of the arch for
Accepted Article the control group. both groups.

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 Table 2: Quantitative analysis describing mean values and standard deviations for all variables analyzed.
Accepted Article
Kau et al. 200413 (RCT) Sjögren et al., 201214 (RCT) Sayin et al. 200615 (CCT)
Lower arch
Extract
Extraction Extraction Extractio Etraction-
Control ion- Control Extraction Control
Group Group n-Control Control
Control Group
Methodology Plaster models Plaster models Plaster models and cephalometry
Follow-up (m) 19 16 3 12 12 0 12 12 0
n 53 30 23 32 41 -9 16 16 0
Dental Crowding T1-T0 -6.03 ±4.44 -1.27 ±2.44 -4,76 -1.88 ±2.23 -0.50 ±1.09 -1,38 -- -- --
Arch length T1-T0 -3.16 ±2.95 -0.43 ±1.51 -2,73 -1.05 ±0.78 0.03 ±0.67 -1,08 -0,21 0,12 -0,33
Intermolar Width T1-T0 -0.11 ±1.31 0.32 ±0.78 -0,43 -0.18 ±0.47 0.23 ±0.45 -0,41 0,32 0,39 0,07
Overbite T1-T0 0.76 ±0.98 0.37 ±0.98 0,39 0.58 ±1.09 0.10 ±1.09 0,48 -- -- --
Overjet T1-T0 -0.12 ±1.06 0.28 ±0.91 0,4 -0.35± 0.87 0.16 ±0.77 -0,51 -- -- --

(Bold= p<0.05; RTC: randomized clinical trial; CCT: prospective clinical study.

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Accepted Article
Table 3: Risk assessment for controlled clinical studies using ROBINS I-tool.

DOMAINS/ ROBINS-I-TOOL

PRE-INTERVENTION INTERVENTION POST-INTERVENTION

Risk of bias Risk of bias Risk of bias Risk of bias in Risk of Risk of bias Risk of bias in General
AUTHOR
due to in the in the the deviation of bias due in the the selection of Judgme
confusion selection of intervention the intervention to lack of measuremen reported nt of
participants classification plan data t of results results Rob
Sayin et al.15
Moderate Serious Low Low Low Low Low Serious
(2006)

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 Table 4: Risk assessment for randomized controlled clinical studies using Rob2.
Accepted Article
DOMAINS/ ROB 2
Bias arising Bias due to Bias due to
Bias in Bias in
from the deviations from lack of General Judgment of
AUTHOR measuring Results
randomization intended outcome RoB
results Selection
process interventions data
Kau et al.13 (2004) Low Low Low Low Low Low
Sjögren et al. 14 (2010) Low Low Low Low Low Low

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Accepted Article
Table 5: Summary of GRADE applied to the results from the meta-analysis of the different measures evaluated.

Evaluation of certainty № of patients Effect

№ of Risk Ratio Certain Importance

Risk of Canine
Study design Inconsistency Indirectly Inaccuracy Other Considerations Control
studies bias Extraction (95% CI)

Anterior tooth crowding

2 Experimental Not to the response RR -2.83 ⨁⨁⨁⨁

Not serious Not serious Not serious Not serious 85 exposed / 71 not exposed
studies gradient (-3.56 a -2.09) HIGH CRITICAL

Arch length

Experimental RR -1.26 ⨁⨁⨁⨁

2 Not serious Not serious Not serious Not serious none 85 exposed / 71 not exposed CRITICAL
studies (-1.58 a -0.94) HIGH

Intermolar change

Experimental RR -0.41 ⨁⨁⨁⨁

2 Not serious Not serious Not serious Not serious none 85 exposed / 71 not exposed CRITICAL
studies (-0.61 a -0.22) HIGH

Overbite
RR 0.43
Experimental ⨁⨁⨁⨁
2 Not serious Not serious Not serious Not serious none 85 exposed / 71 not exposed (0.10 a 0.76) CRITICAL
studies HIGH

Overjet
2 Experimental Not serious Not serious Not serious Not serious Not to the response 85 exposed / 71 not exposed RR -0.11 ⨁⨁⨁⨁ CRITICAL
studies gradient (-0.40 a 0.18) HIGH

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Accepted Article

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